| Certificate Number | 111 | | Date Issued |
| Child Given Name | |
Jrouex | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 20 Feb 1889 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Julius |
Jrouex | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Canada | 45 | Father's Age |
| Mother's Given Name | Ellen | Desmais | Mother's Maiden Name |
| Mother's Nationality | | Canada | Mother's Birth Place |
| Mother's Age | 38 | 7 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Stitzell | Nevada IA | Medical Attendant's Address |